The Minimally Invasive
"Simpler the better" and "Less is more"
Varicose vein, a disease of the superficial venous system, is characterized by a weakness of the vein wall causing vein distention/dilatation. Once distended /dilated, most valves, along the diseased vein, will become incompetent. This means: they will leak and the normal uphill - back to heart - blood flow, with the help of gravity, will reverse course and become a downhill flow, back to calf/ankle. This flow pattern is called reflux. That is the scenario only if the patient is upright on his/her feet. With patient recumbent, even better with elevated leg, the favorable gravitational forces, will automatically facilitate resumption of the normal uphill back-to-the-heart flow. (One can easily understand now the temporary, but beneficial effect of leg elevation.)
To make all this and the following sentences easier to understand, let's imagine an overflowing faucet. Obviously the escaped water, aided by (the same) gravity, in a free fall fashion, will be flooding the floor. Once leaking faucet is fixed and overflow properly controlled, future flooding should be prevented.
Fig. 1 Normal (uphill) and pathological (downhill) flow at the groin junction between the superficial long saphenous vein and femoral vein.
Truncal varicose veins (VV) present a very similar scenario. The "faucet"/escape point is, however, located either in the groin or behind the knee, places were leg’s superficial vein (called saphenous) will join deep veins (femoral in the groin; popliteal behind the knee), sites called junctions (SFJ respectively SPJ). These two junctions are normally protected by a major valve responsible not just for maintaining the normal back-to-the-heart, uphill flow but also to drain the blood from the superficial system into the deep. Therefore, as long as this valve is competent i.e. normal, in no circumstances blood, from the larger deep vein can spill into the superficial vein. Never! However, in the presence of a leaky i.e. incompetent junctional valve, blood from the deep vein, helped by gravity, (like the water in the presence of an overflowing faucet mentioned above), will escape into the superficial vein and will start its journey in an reversed, downhill fashion, flow pattern called reflux.
Obviously, blood will not be “flooding" floors, but disease affected and already distended, bulging branches/tributaries of the vein that caused patient’s cosmetic distress in the first place. If, with passage of time venous pressure rises too, the patient may become symptomatic complaining of discomfort, pain, ankle swelling and complications such as superficial phlebitis, chronic venous insufficiency, venous ulcers may occur.
The main difference between the two scenarios is that water flooded the floor in a free fall fashion, while blood, in its downhill/reversed course, uses as a conduit, the existing axial superficial vein trunk extending from the groin junction to ankle (the long saphenous vein) or from behind the knee junction to the ankle (the short saphenous vein). This conduit, in normalphysiologic conditions, collects uphill flowing blood through attached branches/tributaries existing along the entire leg. In varicose veins, as previously mentioned, flow is reversed i.e. downhill, from the axial vein into the branches/tributaries. Positioned in slightly deeper structures of the thigh and calf, in most cases, this axial vein is not visible. (For more detailed information please read anatomy and physiology.)
To achieve the best therapeutic result, any treatment modality available for varicose veins has to follow three major steps. (See drawing).
STEP 1. The method has to completely close/obliterate/stop the leakage of blood originating at the level of the escape point/junction regardless its position : groin or behind the knee.
STEP 2. The method has to also stop (remove or close) the downhill pattern of blood flow existing in one the saphenous vein trunks (either along the inner aspect of the thigh or along the hind side of the calf) being the conduit enabling the downhill/reversed pattern of flow ("reflux"), and permitting large volumes of blood to spill/”flood” the branches/tributaries of the axial vein causing them further to distend/bulge.
STEP 3. The method lastly, should also take care of the distended and bulging tributaries either removing or closing them, and if just possible, in the same session.
Truncal Varicose Veins:
Principals of care. (Click to enlarge)
The minimally invasive "revolution" in surgery started practically in the late seventies, early eighties with the performance of the first laparoscopic appendectomies by Drs. de Kok (Netherlands) and Semm (Germany) followed in 1985 by Dr Muhe (Germany) with the first laparoscopic ("keyhole") cholecystectomy. From that moment on, the practice of surgery was turned on its head so much so, that today's keyhole minimally invasive techniques have - in almost all elective cases - completely replaced old and open (pelvic, abdominal, retroperitoneal and thoracic) procedures.
The traditional and historic stripping surgery was pioneered in the US (Keller, Mayo, Babcock) at the turning of the 20 Century and while medically and hemodynamically sound as it rid patient’s varicose veins by strictly following the previously mentioned three steps, it had excessive components embedded in the procedure among them an over-sized stripper 's head (attached to a long wire and meant to remove basically "yank" - what we know today unnecessarily - the entire axial vein), head directly responsible for excessive soft tissue trauma frequently including two major sensory nerve, one in the thigh, the other in the calf. The procedure was also a cosmetical disaster as it left behind a limb crisscrossed by unacceptable and ugly scars. Certainly, it was expensive as it had to be performed in a hospital setting and general/epidural anesthesia. Convalescence of several weeks and loss of income was the rule rather than exception and the procedure was dreaded by patients and disliked by surgeons as well. Therefore, the search for a tamed surgical alternative was understood and when finally arrived it was much welcomed. Changes came slowly but today we indeed have an excellent minimally invasive alternative pioneered in Europe by mainly two Swiss physicians.
Doctor Muller (a dermatologist) is first to introduce,already in mid sixties (!), his specially designed mini- hooks (see picture) for removal of the varicose branches through hardly visible 1-3 mm long skin openings (Fig. 9-10) demanding only "butterfly" tape closure thus replacing the generous skin openings of the traditional approach and stitches. Operative time and trauma were minimized and scars linked to the traditional approach were completely eliminated, correcting the cosmetic disaster left on patient's leg(s) by the historic approach.
The Oesch hooks (click to enlarge)
"Peeling out" the axial vein. The encircled in red the small Oesch's PINstriper head that INFOLDS the vein in itself and pulls it out so that the inner lining turns to be on the outside and the outer lining in the inside. This is the reason there is no tissue trauma ALWAYS encountered with the traditional outdated stripping. Therefore, the entire single session protocol becomes performable in local anesthesia and office setting with NO down time!! (Click to enlarge)
Dr. Muller's hooks (Click to enlarge)
Removal of vein with
1-3 mm skin openings
with help of hooks. (Click to enlarge)
The exteriorized vein is cut and removed segment by segment. The number of skin openings is unimportant as no scars will be left behind. (Click to enlarge)
Fig. 12 "Peeling off" a glove...Indeed the inner surface of the glove that was in contact with the skin becomes now the outer surface as the glove comes off the hand. This is the principle of the invaginated and minimally invasive stripping... (Click to enlarge)
The minimally invasive a-traumatic inversion/invaginated ("peel out") stripping took sometime to mature. Colleagues from Belgium and Germany introduced novel options however, at the present the surgical establishment is using Dr. Andreas Oesch’s (of Bern, Switzerland) PIN (standing for perforate/invaginate) stripper that has a minute head not bigger than a match's head that UNFOLDS the vein to be removed eliminating any possibility of surrounding tissue trauma. (Fig. 11) (Please imagine removing the axial vein as you would remove/peel off a glove from a hand it covered. (Fig 12)
Without going into details the tissue trauma is so minimal when using this ingenious device, that the entire protocol can be performed in an office setting, under a simple local (femoral block) anesthesia and without any down time. Yes, convalescence is eliminated at least in my set up as in over 3500 surgeries I have never given a certificate of leave of absence. In conclusion, the previously mentioned three hemodynamic principles required for any varicose vein procedure to deliver excellent immediate and late results (Step 1; Step 2, Step 3) are easily and atraumatically accomplished by this method.
I take pride of being the first to introduce both, the ambulatory hook phlebectomy (“phlebos”, vein in Greek) as well as the invaginated PIN stripping to the American surgical establishment. I also take pride that I am quite unique by performing this protocol in an office setting, similarly with the much trumpeted venue used for sclerotherapy and endovenous thermal ablations. There are however major differences as the minimally invasive surgical approach presented here, besides delivering a much better immediate and late cosmetic results, does not carry the severe thromboembolic complication possibilities the high tech ultrasound guided foamed sclerotherapy and endovenous thermal ablation could have. These two high tech approaches are however, presented and promoted to the lay public, as well as naive and uninformed physicians, as the ONLY office alternatives to surgery. However, they deliberately do not want differentiate between the two existing yet totally opposing surgical options: the obsolete traditional surgery and the minimally invasive approach just described.
Since the beginning of the nineties I have successfully performed over 3500 surgeries of the kind. All procedures were performed in my office and local anesthesia and so far I did not write not one single certificate of leave of absence. By eliminating hospital and anesthesia fees this approach is very cost efficient. The procedure takes 1 to 2 1/2 hours to accomplish. Bilateral cases are operated in two different sessions. No stitches are required except in cases the escape points is to be ligated in the groin or behind the knee. They will be absorbable stitches so nobody has to remove them. The multiple 1-3 mm skin openings needed for removal of the varicose branches are closed with only simple tapes ("butterflies") and will never leave scars behind. Dressing is minimal, a light stocking is used for daytime compression and for one single week only. Patient drive themselves away or are driven if they preferred a tranquilizer encountered in 10-15% in my patient population. All patients return to normal daily activities sporting activities included except swimming. Pain is so minimal not even OTC pain medication are rarely used and if yes, only for the first night. Controlled substances were never prescribed. Results are basically immediate and cosmesis is exceptional ( please see the picture gallery below). As to complications, there is nothing out of the ordinary to report. Blood clots were not observed not in superficial and not in deep vein systems. Bruising usually is minimal and self-limiting, disappearing completely in 1-3 weeks.
Antibiotics are never used routinely as skin infections are very, very rare. Allergic reactions to local anesthetic were never observed, besides, everybody by the time need vein treatments, have visited a dentist and allergy to the only drug used (xylocaine) would have been disclosed during the consultation. Occasionally, the two minimal complication seen were self limiting in form of small lymphatic collections and nerve injuries mainly in the foot, ankle and shin area. They are caused by inadvertent injury to small lymphatic vessels or peripheral nerve fibers existing along the veins when attempting to remove them.
Long term recurrence being the rule rather than the exception have been obviously observed. The ten year recurrence rate witnessed was estimated to be between 8-10%, which is more than acceptable. It happened mainly in the women population who got pregnant and delivered years after the initial procedure and in whom a family tendency for the condition was very obvious.
Before and After Gallery
Goren, G., Yellin, A.E. Surgery for truncal varicose veins: the ambulatory stab avulsion phlebectomy.
Am J Surg 1991; 162:166-74 also published in Year Book of Surgery 1993:385-87
Goren, G., Yellin A.E. Invaginated axial stripping and stab avulsion phlebectomy: a definite outpatient procedure for varicose veins.
J Vasc Surg 1994; 20:970-77
Goren, G., Yellin, A.E. Invaginated axial saphenectomy by a semirigid stripper: PIN stripping.
Amb. Surg 1994; 1: 27-35
Goren, G., Yellin, A.E. Minimally invasive surgery for primary varicose veins: limited Invaginated axial stripping and tributary (hook) stab avulsion.
Ann Vasc Surg 1995; 9:401-14 also fully translated in the French and Spanish surgical literature.
Goren, G. Yellin AE. Hemodynamic principles of varicose vein therapy.
Derm. Surg. 1996; 22:657-60